Programming ovulation in the menstrual cycle by a simple innovative approach: back to the future of assisted reproduction.

OBJECTIVE: To synchronize the intercycle FSH elevation with exogenous E2 for programming ovulation in the menstrual cycle. DESIGN: Open single-arm study. SETTING: Teaching hospital. PATIENT(S): Twenty-six patients with infertility whose menstrual cycles normally lasted 25-35 days and who underwent our routine programming method for postcoital tests and ovulation evaluations. INTERVENTION(S): Participants received estradiol valerate (2 mg) twice a day from day 25 of the previous cycle until 1-15 days after the onset of menses. Women had ultrasonography on the last day of E2 treatment or on functional day 0 and 13 days later or on functional day 13. Hormones were determined on functional days 0, 3, 9, and 13. The increase in FSH in response to E2 withdrawal was defined as deltaFSH. MAIN OUTCOME MEASURE(S): LH surge and other ovulatory indices on functional day 13. RESULT(S): On functional day 13, 73% of the women had an LH surge. Fifteen percent had evidence of previous ovulation with low LH and elevated plasma P levels, and the remaining 12% had low LH levels and no evidence of past or imminent ovulation. Women with evidence of early ovulation were older and had higher FSH signal amplitude. CONCLUSION(S): It is feasible and practical to program ovulation in the menstrual cycle with exogenous E2. In 73% of women, the true duration of the follicular phase (intercycle FSH elevation to LH surge interval) remained constant (13 days). Hence, common fluctuations in menstrual cycle length mainly result from variations in the timing of the intercycle FSH elevation. Although rare, truly short follicular phases also exist (15%). This simple and practical system for programming natural ovulation offers new possibilities for using the menstrual cycle in assisted reproductive technology, at least in selected individuals.

Are women requiring unplanned intrapartum epidural analgesia different in a low-risk population?

We studied 645 full-term low-risk women in early labour in 6 units to evaluate the effects of maternal characteristics and obstetric management in early labour on the use of epidural analgesia, and to analyse the relationship between epidural analgesia, progress of labour and mode of delivery using multiple logistic regression. Among variables present in early labour, nulliparity, ethnicity and obstetric unit were the strongest predictors of epidural analgesia requirement. In nulliparous women, obstetric unit affected use of epidural analgesia (P<0.05) and induction of labour was associated with increased use of epidural analgesia (odds ratio 3.45, 95% CI: 1.45-7.90). In multiparous women, only ethnicity was statistically significant (P<0.05). Epidural analgesia was associated with longer labours and more instrumental deliveries (odds ratio 2.93, 95%CI: 1.48-5.83). In the epidural group, however, we found a positive correlation between first stage duration and elapsed time before epidural analgesia. Furthermore, rate of cervical dilation was similar in the non epidural group throughout the first stage (mean 3.41 cm/h, 95%CI: 3.19-3.63) and in the epidural group after epidural analgesia decision (mean 3.99, 95% CI: 2.96-5.02), while the mean cervical dilatation rate before epidural analgesia was 0.88 cm/h (95% CI: 0.72-1.04). The need for epidural analgesia is, therefore, multifactorial and difficult to predict. Whereas nulliparity increases epidural analgesia requirement, data on the progress of labour before pain relief suggest that epidural analgesia is a marker of pain severity and/or labour failure rather than the cause of delayed progress in low-risk pregnancies.

[Value of Doppler velocimetry of the umbilical artery, aorta, cerebral artery, and uterine artery in pathological pregnancies]. / Intérêt de la vélocimétrie Doppler ombilicale, aortique, cérébrale et utérine dans une population de grossesses pathologiques.

This prospective study try to evaluate the predictive value of Doppler umbilical artery in the diagnosis of intra-uterine retardation (IUGR) and fetal distress requiring operative delivery. We use the blood flow class (BFC) to characterize the blood velocity waveform. Like others, we found a strong negative correlation between the blood flow class and fetal weight at delivery. When the umbilical BFC is abnormal in case of suspicion of IUGR, the diagnosis is confirmed at delivery in 100%, but in case of umbilical BFC 0, we found only 53% of IUGR. If we consider the mode of delivery, we found 7% of cesarean section for fetal distress in BFC 0, 38% in BFC1 and 78% in BFC 2-3. We had 5 fetal death, two cases with malformations, non-immunologic hydrops and trisomy 18. The others three were severe IUGR, in all cases the umbilical Doppler BFC was abnormal. Another parameter was significantly modified in case of fetal distress: the cerebro-placental index. This confirm the brain sparing phenomenon. We found a prevalence of IUGR of 43% in the high risk pregnancies group. The positive predictive value of umbilical Doppler is 82%, but the sensitivity is low, 44%. The efficacy of umbilical Doppler to predict the occurrence of operative delivery for fetal distress is better, because the prevalence is lower, 18%, the positive predictive value is 60% and the sensibility 70%. There is non doubt that, fetal blood flow is a secondary test of great value in identifying fetuses at risk of perinatal hypoxia.

[Value of Doppler of the uterine arteries and the association of uterine and umbilical velocimetry in pregnancies at risk]. / Apport du Doppler des artères utérines et de l'association de la vélocimétrie utérine et ombilicale dans les grossesses à risque.

This study was designed to evaluate the role of Doppler velocimetry of uterine artery and of the association of uterine and umbilical artery. We use the index of Stuart S/D to characterize the uterine waveform. A value greater than or equal to 3 and/or the persistence of a notch is considered abnormal. When the uterine artery is pathological, we find more proteinuric hypertension, the incidence of intrauterine growth retardation (IURG) twice (p less than 0.001), the birthweight is significantly lower; the caesarean section rate for fetal distress is 35% for 11% in the other group (p less than 0.005), but the caesarean section rate for maternal indication is the same in the two groups. If we test the efficiency of the uterine Doppler study in prediction IUGR, we obtain a sensitivity of 42.5% and a positive predictive value of 74%. The population of high risk pregnancies is divided into four groups according to the Doppler findings. The first group contain normal values in the uteroplacental circulation and in the umbilical vessels, this association predict a normal outcome. The second group contain normal umbilical artery flow velocity waveform (FVW) and abnormal uteroplacental FVW, this pattern is associated with more severe hypertension and a rate of caesarean section of 16%. The final two groups contain patients with abnormal umbilical FVW and either normal or abnormal uteroplacental FVW. We find in these two groups the more complicated neonatal evolution, the incidence of caesarean section for fetal distress is more than 50%, the rate of IUGR is between 82% and 100%. The examination of the uteroplacental vessels permit the selection of patients with high risk of chronic fetal distress, therefore these pregnancies will have intensive surveillance with biophysical profile, umbilical and cerebral Doppler.

[Measuring fetal ischemia using multichannel pulsed Doppler sonography of the aorta and umbilical vein. Preliminary results in normal pregnancy]. / Débimétrie foetale au moyen d'un Doppler pulsé multicanaux dans l'aorte et la veine ombilicale. Résultats préliminaires dans la grossesse normale.

The recent development of ultrasound techniques linked to a continuous or pulsed Doppler system allows an immediate and atraumatic study of fetal blood flow to be performed. Using pulsed Doppler techniques, blood velocity waves can be analyzed and blood flow can then be calculated using ultrasound to determine the diameter of the fetal vessel; the result is expressed in milliliters per minute. A study of aortic and umbilical venous blood flow has been carried out with a prototype pulsed Doppler system with 128 gates. The same probe was used to obtain pictures by B mode ultrasound as well as to generate Doppler waves. The study group consisted of 90 normal pregnancies between 32 and 41 weeks of gestation. The umbilical venous blood flow has been measured in 50 subjects and the aortic blood flow in 79 subjects. The average aortic blood flow varied from 345 to 618 ml/min. In the umbilical vein, the flow was between 240 and 420 ml/min. It was noticed that as pregnancy advanced, blood flow slightly increased. The paper discusses the results obtained and the problems encountered with this method.

[Antenatal diagnosis of fetal sex. Method and implications]. / Diagnostic anténatal du sexe foetal. Méthode et implications.

An outline of fetal antenatal sex determination and its diagnostic methods are rapidly enumerated. Actual methods are based on direct and indirect identification of sexual chromosomes from three types of cells : desquamated ones in amniotic fluid, fetal lymphocytes circulating in maternal blood and desquamated chorionic cells from endocervical smear. Three methods are utilizable : evidence of sexual chromatine, fluorescence specificity of the Y chromosome and the karyotype. Cells from amniotic fluid permit a correct prediction up to 97,5 p.100. However, the high risk of contamination limits its use. There is a 86 p. 100 diagnostic certainty with fetal lymphocytes in maternal blood or cervical desquamated chorionic cells. Future sex preselection may be contemplated and along with this the speculative social consequences. On the other hand, sex determination and volontary selection are limited at the moment by available technics and also by scientific and medical ethics.

Epiphyseal tilt produced by experimental overload.

After segmental resection of the diaphysis of the radius in growing dogs, the distal ulna epiphyseal plate is submitted to a mechanical overload which provokes a progressive tilt of the epiphysis. A full exail realignment is developed in two or three months as shown in radiographic follow-up studies. Histologically, the first lesion is a fissure starting and the convex side of the growth line, passing along the epiphyseal plate and located somewhere between the proliferative layer which is seldom affected and the zone of enchondral ossification. The separated segment of the growth cartilage situated between the fissure and metaphysis stops growing and the cartilaginous tissue becomes disorganized and necrotic. It is then reabsorbed, and replaced by vascular-connective tissue coming from the bone marrow. Growth usually goes on form the deep proliferative layer of the epiphyseal plate when its vascular connections are intact. After three months a normal epiphyseal line is rebuilt correcting the defective axis of the bone.

[First evaluation of plasma L-lactate measurements by means of the "lactate analyzer 5400"]. / Premiers essais de mesures du L-lactate plasmatique au moyen du "lactate analyzer 5400"

The instrument used can measure lactate instantaneously by a semi-automatic method using an electrochemical-enzymatic sensor. In order to test the instrument, 3 series of measurements were carried out simultaneously by the Analyzer and by the conventional enzymatic method (Boehringer, Mannheim): "normal" plasma and "normal" blood was obtained from venous blood of healthy adults; pathological plasma, obtained by addition of a known concentration of lactate to normal plasma, was also tested. The correlation curves for these three series are reported. The coefficient r is between 0.95 and 0.98, which bears out the reliability of the measurements. Since a short period, this lactate analyzer is used in our research laboratory in obstetrics.